Permit INCITY OF TIGARD MASTER PERMIT
COMMUNITY DEVELOPMENT Permit#: MST2023-00621
Date Issued: 02/05/2024
TtGAR.D 13125 SW Hall Blvd.,Tigard OR 97223 503.718.2439 Parcel: 2S112CA15200
Jurisdiction: Tigard
Site address: 15583 SW BELLAGIO CT
Subdivision: BROOKSIDE SUBDIVISION Lot: 12
Project: Brookside, Lot 12
Project Description: New attached dwelling. NO FINAL INSPECTION UNTIL DEFERRED SDC FEES HAVE BEEN
PAID.
BUILDING
Floor Areas Required Setbacks Required
Stories: 3 Bedrooms: 3 First: 706 sf Basement: 0 sf Left: 5 Parking Spaces: 0
Height: 34 Bathrooms: 4 Second: 1033 sf Garage: 304 sf Front: 15 Smoke Yes
Dwelling Units: 1 Third: 1052 sf Right: 5 Detectors:
Total: 2791 sf Value: $489,732.87 Rear: 15
PLUMBING
Sinks: 1 Water Closets: 4 Washing Mach: 2 Laundry Trays: 0 Rain Drain: 1 Urinals: 0
Lavatories: 5 Dishwashers: 1 Floor Drains: 0 Sewer Lines: 100 SF Rain Drains: 0 Storm Sewer: 100
Tubs/Showers: 3 Garbage Disp: 1 Water Heaters: 1 Water Lines: 100 Catch Basins: 0
Bckflw Prevntr: 0
Footing Drain: 0 Ice Maker: 1 Hose Bib: 2 Backwater Value: 1
Other Fixtures: 1
Drywell-Trench Drain: 0
Other Fixture Units: Bar sink
MECHANICAL
Fuel Types Air Conditioning: Y Vent Fans: 7 Clothes Dryers: 2
Natural Gas Heat Pump: N Hoods: 1 Other Units: 0
Furn<100K: 1 Vents: 0 Woodstoves: 0 Gas Outlets: 3
Furn>=100K: 0
ELECTRICAL
Residential Unit Service Feeder Temp Srvc/Feeders Branch Circuits
1000 sf or less: 1 0-200 amp: 0 0-200 amp: 0 W/Svc or Fdr: 0
Ea add!500 sf: 5 201-400 amp: 0 201-400 amp: 0 W/O Svc/Fdr: 0
Mfd Home/Feeder/Svc: 0 401-600 amp: 0 401-600 amp: 0
601-1000 amp: 0 601+amp-1000v: 0
1000+amp/volt: 0
ELECTRICAL-RESTRICTED ENERGY
SF Residential
N HVAC: N SecuritySystem:&Stereo: Alarm: N Vaccuum S stem: N Garage Opener: N All Y
Other: N Other Description: Ecompasing:
BUILDING INFO
Class of Work: Type of Use: Type of Constr: Occupancy Group: Square Feet:
NEW SFA VB R-3 2791
Owner: Contractor:
BLACKWOOD HOMES INC BLACKWOOD HOMES Required Items and Reports(Conditions)
PO BOX 4188 PO BOX 4188 1 Ersn Cntrl 503-639-4175
TUALATIN,OR 97062 TUALATIN,OR 97062 2 Fire Rated Conditions
PHONE: PHONE: 503-482-5802
FAX:
Total Fees: $22,971.90
This permit is issued subject to the regulations contained in the Tigard Municipal Code, State of OR. Specialty Codes and all other applicable law. All work
will be done in accordance with approved plans. This permit will expire if work is not started within 180 days of issuance, or if work is suspended for more
the 180 days. ATTENTION: Oregon law requires you to follow the rules adopted by the Oregon Utility Notification Center. Those rules are set forth in OAR
ac9-nn1-M1n thrniinh f1AR Qc 001-MQn Vnii ma‘,nhtain n rnrnr of tha rn lee nr riirart niiactinne to(ll INC by rall'�1 919 1QR7 nr 1 Ann 119 9144
Issued By: Permittee Signature:
1 -ti--' ----,,,\
Call 503.639.4175 by 7:00 a.m.for the next available inspection dat
This permit card shall be kept in a conspicuous place on the job site until completion of the project.
Approved plans are required on the job site at the time of each inspection.
• /2
• Building Permit Application
FUZZ 0111( I. t ,I O\I.1
Received Permit No.:
City of Tigard —^—Date/By: al l�' 1 � VI r?v
23
13125 SW Hall Blvd.,Tigard,OR 97223 ) '"' Plan Review��n r- w p per Permit: t'
e Phone: 503.718.2439 Fax: 503.598.1960 Date/By: / o A4 � ' "?' ' t
Inspection Line: 503.639.4175 Date Ready/By: h•-e�h—: ® See Page 2 for
T 1 G A I l) t i m /"i`2`' Notified/Method: ( O r I`►—6„, Supplemental Information
(14.4.401
Internet: www.figard-or.gov 1
New construction _ 0 Demolition . Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
❑Addition/alteration/replacement 0 Other: equipment,materials,labor,overhead,and the profit for the
�7
CATEGORY OF.CONSrRV TION'
a
. ��/ ,7 3�'
Valuation: $
nd 2-family dwellingi 0 Cornmercial/ihdustrial work indicated on this application.
Number of bedrooms: 20 Accessory building El Multi-familY
❑Master builder ❑Other: Number of bathrooms:
JOB SITE INFORMATION AND LOCATION. Total number of floors: 3i.�
r
Job site address: /55—B T\ Sti..0WO Cr New dwelling area: 219 1 square feet 1/6c-0_,
City/State/ZIP: -rI11`+[4) cif. 9 741 Garage/carport area: 30Y square feet l D
Suite/bldg./apt.no.: -Project name: Covered porch area: square feet 7000
Cross street/directions to job site: 7 7 714 b (Al Deck area: 7 square feet
Other structure area: square feet
�
1DDAT `' �,� i sCKLIS1
REQj�IR.� � �R i�...
Subdivision: g fVJoCc`� I Lot no.: (2_ Permit fees*are based on the value of the work performed.
Indicate the value(rounded to the nearest dollar)of all
Tax map/parcel no.: equipment,materials,labor,overhead,and the profit for the
`"f work indicated on this application.
Valuation: $
S k ._ ,./i_ir-fl
I Existing building area: square feet
New building area: square feet
' . E ,, :x t ,, I Number of stories:
PROPER( OVI+NER1�+= . . '<� .: �_., x
Name: Blackwood Homes, INC Type of construction:
Address: PO Box 418E Occupancy groups:
City/State/ZIP: Tualatin,OR 97062 Existing:
Phone:( ) r, Fax ( ) New:
Vrr r 6Alin.f 147 z,� :t1 ; e6WR(W gIV1*‘ fi itel,I �y1 y(���� El�.,�ji „,§ 'tY
5 4,i1.,t,, A.Px:V°.�Fk tfeeseta )i'0`-".=,+
Business name: Structural plan review fee(or deposit):
Contact name: Blackwood Homes, INC
PO BOA 4188 _ FLS plan review fee(if applicable):
Address:
Total fees due upon application:
City/State/ZIP:
Amount received:
Phone:( ) LIT gfJl, Fax:.( ) olw a 1F-is
E-mail ia(,kWp90 h Uf) j F.0 e ?retkil co� Commercial and residential prescriptive installation of
,1€ n ,' u . CY. tf ? , w,4,,,` . . V ',-- roof-top mounted PhotoVoltaic Solar Panel System.
Submit two(2)sets of roof plan with connection details
Business name: Blackwood HOmsck INC and fire department access,along with the 2010 Oregon
Address: PO Box 4188 Solar Installation Specialty Code checklist.
Tualatin,OR 97062 Permit Fee(includes plan review $180.00
City/State/ZIP: and administrative fees):
Phone:(SO ) L1r2 5903..pe3.. Fax:( ) State surcharge(12%of permit fee): $21.60
CCB lic.: 14?3 p+ Total fee due upon application: $201.60
Authorized signature:ature: 4..yThis permit application expires if a permit is not obtained
within 180 days after it has been accepted as complete.
*Fee methodology set by Tn-County Building Industry
lPrint name:Aow Date: Il 12:1 I23 I Service Board.
I:\Building\Petmits\BUP-RESPermitApp.doc 02/24/2011 440-4613T(11/02/COM/WEB)
12
Mechanical Permit Application FoRR Orrlc'L t sh:°`I,'
City of Tigard Date/By ^'y�S�c} a rr c'4f,
13125 SW Hall Blvd.,Tigard,OR 97223 Received
Plan Review Permit No.:
71111
Phone: 503.718.2439 Date/By: Other Permit.
Inspection Line: 503.639.417,5- '!�",
TiGARD y Date Read By inns: ® See Page 2 for
Internet: www.tigard-or.gov , ,. _. Notified/Method: Supplemental Information
,ru
' t r. .r s “ "telit tJ4';CA'iefdIST '
Mechanical permit fees'are based on the value of the work
New construction ❑Addition/alt��akt /rFptltlfittt performed.Indicate the value(rounded to the nearest dollar)of all
❑ Demolition ❑Other:-• 't' „, mechanical materials,equipment,labor,overhead,and profit
h " `'. �"' '� 'f }1�Ia ' y Value $
s+s.�'^� .�r -� x.. �`
I-and 2-family dwelling 0 Commercial/industrial 0 Accessory building Fo,specw!Infortion use checklist.
0 Multi-family 0 Master builder ❑ Other: Description Qty. Ea. Total
w ve
.•..s. 1'tl a lv ai �i Heating/cooling:
site"'. /�f 93 s 0 Ct t , r o (_,r Air conditioning 46.75
Job address: 7 �(/rV1 1 46 75
Furnace 100,000 BTU(ducts/vents)
City/State/ZIP: .7 f 'i2 9 Furnace 100,000+BTU(ducts'vents) 54.9I
61 06
Suite/bldg./apt.no.: 1 Project name: Heat pump23 32
Duct work
Cross street/directions to job site: 7 9 rOtI •
Hydronic hot water system 23 32
Residential boiler(radiator or
hydronic) 23.32
Unit heaters(fuel-type,not electric),
in-wall,in-duct,suspended,etc. 46.75
Flue/vent for any of above 23.32
Subdivision: IS,Ki10K5v(v I Lot no.: /X Other: 23 32
Other fuel appliances:
Tax map/parcel no.: , Water heater i 23.32
.' Gas fireplace/insert 33.39
5 F Flue vent for water heater or gas
fireplace 23.32
Log lighter(gas) 23.32
Wood/pellet stove 33.39
Wood fireplace/insert 23.32
Chimney/liner/flue/vent 23 32
I
a Other 23 32 Werr
Environmental exhaust and ventilation:
Name: Blackwood Home, INC Range hood/other kitchen
Address: PO Box 4188 equipment / 33 39
Tualatin, OR 97062 Clothes dryer exhaust
City/State/ZIP: Single-duct exhaust(bathrooms, 33.39
toilet compartments,utility rooms) S 23.32
Phone:( ) Fax:( ) Attic/crawlspace fans 23.32
'.-, t' VWiia '�gNA' :p CQI`}'TACT:PEItSOIY;' Other. 23.32
Business name: ,. INCFuel piping:
Blackwood Homes, N $14.15 for first four;$4.03 for each additional
Contact name: PO Box 4188 Furnace,etc. i
Address:
Tualatin, OR 97062 Gas heat pump
Wall/suspended/unit heater
City/State/ZIP: Water heater 1
Phone:(S$) y(2 $got_ Fax: :( ) Fireplace 0
a
E-mail: , , 6 f t Range / 1
". ,1� Barbecue
1-Mig..Rii ? '��" -', Clothes dryer(gas)
k
`' Other:
Business name: A i K..,,QJ A to _0 L ,,,„0.,,,,....---,
Address: TO £c .,q lt, Subtotal
O i4 �N D� Minimum permit fee($90 00)e
City/State/ZIP: Plan review(25%of permit fee)
Phone:(503) (0 s ' ' 7 tl 2 j, Fax:( ) State surcharge(12%of permit fee)
CCB lic.: .7 r 6 bo 1 TOTAL PERMIT FEE
• This permit application expires if a permit is not obtained within 180
days after it has been accepted as complete.
Authorized signature: �j _�� / • Fee methodology set by Tri-County Building Industry Service Board
Print name:/ �3N (� Date: 1 /1 2.3
I:\Building\Permits\BUP-RESPermitApp.doc 02/24/2011 440-46113T'(l 11l/02/COM/WE
Electrical Permit Application FOR OFFICi: t'Si:()NIA
' Received
City of Tigard Date/B : EEIy� i. +
IIII 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review
I Phone: 503.718.2439 1: Date/B : Related Permit#:
Email: TigardBuildingPermits@Tigard-or.gov Ready Date/By: kris: 6d See Page 2 for
l 1 l \RI) Notified/Method: Supplemental Information
Inspection Line: 503.639 4175 Internet: www ngard-O.f goy d
DI New construction ❑Addition/alteration/replacement Please check all that apply(submit/sets of plans w/items checked):
0 Service or feeder 400 amps or more 0 Building over three stories.
0 Demolition 0 Other: where the available fault current 0 Marinas and boatyards.
,'$ s: exceeds 10,000 amps at 150 volts or 0 Floating buildings.
1—and 2-family dwelling 0 Commercial/industrial 0 Accessory building less to ground,or exceeds 14,000 0 Commercial-use agricultural
amps for all other installations. buildings.
❑Multi family 0 Master builder 0 Other: 0 Fire pump. 0 Installation of 150 KVA or
gig i / cam+ `I4 ,-''f `tf.MVItr-'1 '{ 4x 0 Emergency system. larger separately derived
0 Addition of new motor load of system.
Job#: Job site address: is -Dn 3 Sol .tu,1 C,t C Cr 100HP or more. ❑"A","E","l-z","1-3",
� q ❑Six or more residential units occupancy.
City/State/ZIP: 7 1(n�/n`{� O . l ZZ y .❑Health-care facilities. 0 Recreational vehicle parks.
Suite/bldg./apt.#: I Project name: 0 Hazardous locations. 0 Supply voltage for more than
1//�� '�r1{ Tb 1 /fit{ ❑.yService or feeder 600 amps or more. 600 volts nominal.
Cross street/directions to job site: `/
Description Y . Qty. Each 1 Total i*
New residential single-or multi-family dwelling unit.
Subdivision: Sik)(41.9f1; I Lot#: 'aN Includes attached garage.
1,000 sq.ft.or less 168.54 4
Tax map/parcel#: Ea.add'I 500 sq.ft.or portion 33.92 1
.- ;,~1� ' `,s v°�r_ E.-.; . t, Limited energy,residential 75.00 2
NSF K (with above sq.ft.)
Limited energy,multi-family 75.00 2
residential(with above sq.ft.)
6 qr
Renewable Energy ❑ See Page 2
` ' _;.' , ,,., ti , �,�' = , , g�._ ' , .' Services or feeders installation,,alteration,and/or relocation
Name: 200 amps or less 100.70 2
Blackwood Humes, INC 201 amps to 400 amps 133.56 2
Address:
PO Box 4188 401 amps to 600 amps 200.34 2
City/State/ZIP: Tualatin, OR 97062 601 amps to 1,000 amps 301.04 2
Phone:( ) Over 1,000 amps or volts 552.26 2
Temporary services or feeders installation,alteration,and/or
Email: relocation
Owner installation:This installation is being made on property that I own which is not 200 amps or less 59.36 1
intended for sale,lease,rent,or exchange,according to ORS 447,449,670,and 701. 201 amps to 400 amps 125.08 2
Owner signatu Date: 401 amps to 599 amps 168.54 2
4 Branch circuits—new,alteration,or extension,per panel
'" A1'pIL�#CANT �Q `''- �A � Y � �����" s� A.Fee for branch circuits with
Business name: Sol(A. Elk& above service or feeder fee, 7.42 2
each branch circuit
Contact name: B.Fee for branch circuits without
S`( �L��_I service or feeder fee,first 56.18 2
Address: 'VZ- G Y" branch circuit
City/State/ZIP: Each add'l branch circuit 7.42 2
Miscellaneous(service or feeder not included)
Phone:( ) Each manufactured or modular 67.84 2
dwelling,service and/or feeder
Email: Reconnect only 67.84 2
Ex ';: ; iXe :0 r.. i.. .'.. ' Pump or irrigation circle 67.84 2
Business name:SUNLIGHT ELECTRIC INC Sign or outline lighting 67.84 2
Signal circuit(s)or limited-energy ❑ See Page 2 2
Address:2804 NE 65TH AVE, SUITE D panel,alteration,or extension.
Each additional inspection over allowable in any of the above
City/State/ZIP:VANCOUVER, WA 98661 Additional inspection(1 hr min) 66.25/hr
Phone:971-222-5758 Fax:( ) Investigation(1 hr min) 90.00/hr
Industrial plant(1 hr min) 78.18/hr
Email:PETER@SUNLIGHTELECTRICINC.COM Inspections for which no fee is 90.00/hr
CCB Lic.:172549 Electrical 2 Suprv.Lic.:6652S s(ecifically listed(Vs hr min
,
Suprv.Electrician signature,requi : Subtotal:
Print name:YEGOR , -EN Date:01/25/2023 0 Plan Review Required(25%of permit fee):
State surcharge(12%of permit fee):
TOTAL PERMIT FEE:
Or r
Authorized signature: This permit application expires if a permit is not obtained within 180
Date:01/25/2023 days after it has been accepted as complete.
Print name:Peter Kozarez * Number of inspections allowed per permit.
1:\Building\Permits\ELC PermitApp_ELR ERE.doe Rev 06/I7/2015 440-4615T(I i/05/COM/WEB
/ �
Plumbing Permit Application
Building Fixtures FOR OFFICE: It ONEv
Tom _--k
City of Tigard Received' Date/By: Permit No.:r'1STaco...
co.. 3,.G%y.:0).l
11 U 13125 SW Hall Blvd.,Tigard,OR 97223 Plan Review V
I Phone: 503.718.2439 Fax: 503.598.1960 E; e , , DateBy: Other Permit No.:
InspectionLine: 503.639.4175
T I G.4IZ D Date Ready/By: kris: ® See Page 2 for
Internet: www.tigard-or.gov r»• ; Notified/Method: Supplemental Information
l'/ New construction ❑Demolition L For special information use checklist
Description I Qty. I Ea. I Total
❑Addition/alteration/replacement ❑Other: New 1-2-family dwellings(includes 100 ft.for each utility connection)
` a;e) € �s C ) r s i 4T SFR(1)bath 312.70
.-..�_. `W. _ may.• , ,?:a
ri 1-and 2-family dwelling ElCommercial/industrial SFR(2)bath 437.78
SFR(3)bath / 500.32
❑Accessory building ❑Multi-family• Each additional bath/kitchen i 25.02
❑Master builder ❑Other: Fire sprinkler( sq.ft.) Page 2
.,' t�Q,. . . r.. x k, , , Site utilities:
�,���+,.`� � '� 4att�}3F7 u V 4 !�� k It 4F� � 1 '�1E fi �F Ek�h. ,�"�.., � F.. .-�i.
Job site address:F /�s a 3 S 1,�1 �i,(,�-�0 L., Catch basin or area drain 18.76
Y A fl O 9Y i Drywell,leach line,or trench dram 18.76
City/State/ZIP: 1 1. t` 1 2.2.q
Footing drain(no.linear ft.:_) Page 2
Suite/bldg./apt.no.: I Project name: Manufactured home utilities 50.03
Cross street/directions to job site: 7 0! I* '(b LmiciJ Manholes 18.76
Rain drain connector 18.76
Sanitary sewer(no.linear ft.:_) Page 2
Storm sewer(no.linear ft.: Page_ 2
p Water service(no.linear ft.: ) Page 2
Subdivision: A 9 Q V41,j)i, I Lot no.: 1 Fixture or item:
Tax map/parcel no.: Backflow preventer 31.27
77 ,`_ Backwater valve 12.51
C 25.02
/_ _._ Clothes washer
?r Dishwasher 25.02
Drinking fountain 25.02
Ejectors/sump 25.02
Ti x� i t € ka ': .. s "c r t: '.. - - Expansion tank 12.51
tx,,.asua,-s�r_ _- x ... r. _ �.:c*.w.+P...... a+si .K...�...�Y,. a..i.: d u"-:ri.ic.f�1s;.:r�*.
Fixture/sewer cap 25.02
Name: Blackwood HOm03, INC Floor drain/floor sink/hub 25.02
Address: PO BOX 4188 Garbage disposal 25.02
city/State/ZIP: Tualatin, OR 97062 Hose bib 25.02
Phone:( ) Fax:( ) Ice maker 12.51
7; L r,s t z , L} ,fr e c 'c k - r9` Interceptor/grease trap 25.02
Business name: � • G tO j/l'`ISI ll(,� Medical gas(value:$ ) Page 2
'f Primer 12.51
Contact name:
Roof drain(commercial) 12.51
Address: Sib CAU:1‘11 Sink/basin/lavatory 25.02
City/State/ZIP: Solar units(potable water) 62.54
Phone:( ) Fax::( ) Tub/shower/shower pan 12.51
E-mail: Urinal 25.02
Water closet 25.02
.�
� «�. ' � 4s I "v _-s „ si t t 3 �c yE,.- . - 37.52
.._. , .-. - _...... _. _s,..a,. _-.�_. .,. ,._r. .-' If.'"'_.. :'. ... - Water heater
Business name: I'\, G Q IjmgV'&. Water piping/DWV 56.29
Address: /60 So RI Rk W ft v Other: 25.02
City/State/ZIP: n��Goli (A-Di1 Subtotal
Phone:(Sp 3) 113_ 9 2 q t{ Fax:( ) Minimum permit fee: $72.50
CCB Lic.: /6 b(D 9C/ I J Plumbing Lic.no.: p g s Plan review (25%of permit fee)
State surcharge(12%of permit fee)
Authorized "�' TOTAL PERMIT FEE
signature:
i,_71, 7 This permit application expires if a permit is not obtained within 180 days
Date: II after it has been accepted as complete.
Print name: Q'f _iDr(Q *Fee methodology set by Tri-County Building Industry Service Board.
I:\Building\Permits\PLMU-PermitApp.doc 10/01/09 440-4616T(l0/02/COM/WEB)
� 4 r,
- /
:Ihi a Building Division
One & Two-Family Dwelling
TI G„RD T 0-
Fees Checklist
PERMIT INFORMATION: Application Date - FEE VERS1(1N 1J1 7 ZbZ(2)
1/7 .
Permit #: yy\sTz,02 \ Plan #: Floors: 3
Valuation: (:o\s-ered Porch: Basement
Bedrooms: Deck: -72_, I" Fl(,ur -70(e
WC (toilets) 4 I)eck Cover: 2 1 !door L 03`.
I avat(>ries Patio Corer - Floor
b $
1'ub/shower "1 Accessory Struct. r R-3 7'ota1
L _ etiIf:L._ A
Water Heater 1 /C1as I/lec Garage
Exhaust Vents 7 Gas Flue Vents - -rota] for lice. 3e95--
--------- -------------
Backflovy Prey. :urnac / Heat Pump # for Electrical
BBO --, (;as Fireplace #1:uel lines
2 Ci 0 -e- L c..-. (
FEES: Description: Fee Applies: Fee Entered:
DC Prop- Reyes: Planning / -Info Proc `-arch: L, 52.U0 (over 1 1 NIA) ><Z1 8 ,t awe
Info Proc/Arch: Sm S.50 (up to 1 1 yl') �� I G
Metro CET: Residentialsc lz_____
- -School CET: District: tc--.--A -17:
Tigard CET: ldmin - - --Tigard CFT: ODHCS --_ - -- - --
Tigard Cu T: AH -
Electrical Permit: Permit Fee:
Limited Energy: - ---- -
12"o State Surcharge --- / --- - --- `----
Nlech. Permit: Permit Fee: AZ
12 o State Surcharge ��/ -Plumbing Permit: Permit Fee: -
12"o State Surcharge
1_:rosion Control: w/Permit - Ping 1/7
I:A IiuldinL\I'unn 2 Resl'I.tn(:hrc .s_Uec'_U» \-A.,iuc 12i_'1;22
Page I
❑ Yes ❑ N /A Clean Water Services - Service Provider Letter (lot platted prior to 9/10/1995)
❑ Yes o ON/A Public Facilities Improvement (PFI) Permit:
LA. rAcculti‘
Required: 0 Yes 0 No WtiO/ off"
Applied For: 0 Yes 0 No, stop intake laartl alu
❑ Sensitive Lands: 0 Yes 0 No
❑ Main Land Use Case #s: SD Z2 2. - ce::::› onditions met
❑Applicant notified of land use ex o' ion date: -tent.petmihs7 i}` it ZGa I P F7n4L I?y Volt?
Approved By Planning: Date: I It R/Z-
Notes I polttbe_ fI(1POke0 To I , QetQ al>siltiCr-i— in CON rb ile sibanntO 4 i4�QT O
Revision 1: 0 Approved 0 Not Approved Date: a^
Revision 2: 0 Approved 0 Not Approved Date:
Building Permit Submittal
kir
Original Submittal Date: 12/(1 /Z";;'-'3 12AY_
Site Plans #:
Building Plans #: ?,
ea Building Permit #: Building permit # entered 9n page 1 ,n� ",i '
Workflow Routing: Ed Planning le Engineering Iv1 Permit Coordinator 44 Building
Workflow Sign-off: d ign-off for Planning (include notes from planning review)
Route Documents: Id Engineering: (1) copy of permit application, (1) site plan, (1) building plan
aind original plan review routing form.
r Bid Building: original permit application, site plans, building plans, engineer and
beam calculatio and trust details, if applicable, etc.
•
Permit Technician ��'� Date: I��t1/V)2-.3
Notes:
Engineering Review
c❑ P I Permit:
-tope at building pad: /A %
' onditions met prior to issuance of permit
('Easements (encroachments) per engineering conditions of approval and plat
ifWater Quality/Quantity Facility:
Assess Water Quality Fee in-lieu: 0 Yes IfrNo
Assess Water Quantity Fee in-lieu: 0 Yes &ft
LIDA Facility on lot: 0 Yes e'Sio Add Fee: 0 Yes 0 No
( ,[�inal Plat Recorded
,t 17 NOT Appro d• Date: 7/3A
� Notes: �v ' i fl , ll!
t
Approved By Engineering: Date: //20/Qf
Revision 1: 0 Approved 0 Not Approved Date: G
Revision 2: 0 Approved 0 Not Approved Date:
Permit Coordinator Review
Conditions met prior to permit issuance
❑ Approved, NOT Released: Date notified applicant:
NC Revisions Required: .%2
Date notified applicant: '' (g-et
DC Exemption: 0 Applied for 0 Received,,.- Soes not apply
DC Fees Entered: Wash Co Trans Dev Tax: Yes 0 N/A
Tigard Trans SDC: Yes 0 N/A Deferred
Parks SDC: Yes 0 N/A Deferred
LIDA ❑ Yes ,g131/A 1�
OK to Issue/Approved by Permit Coordinator: Date: 1 1' 1 v ill
1: 0 Approved 0 Not Approved k3)12Date:
Revision 2: 0 Approved 0 Not Approved Date: